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The Bank Robber

What sources of information are ordinarily relied upon in order to make practice decisions? To answer this question, consider the situation of a mental health provider in private practice offering counseling services to a variety of walk-in clients. Suppose further that one particular client has come to seek the therapist’s assistance in treating his depression. During a counseling session, he tells the therapist that he feels guilty over his commission of a bank robbery some 15 years earlier, which the police have never solved. How should this client’s revelation guide the therapist’s clinical conduct with the client? What decisions are to be made from a professional standpoint relative to this client’s treatment? The therapist’s personal sense of morality, professional ideology, or religious conviction may suggest instinctively that this person is to be condemned, and that one would be obliged morally to take some action to ensure his prosecution. Clinical training, however, my compel the therapist to continue to counsel this individual in order to ascertain what mental health issues, if any, may be driving this person’s revelation. Moreover, pragmatic considerations may lead the therapist to believe that there is little the therapist can do realistically in the way of informing any civic authority without the client’s additional cooperation; for example, the savvy therapist may reasonably fear that this client is going to deny having ever told the story as soon as it is revealed to the authorities.

Finding that personal feelings regarding this client are somewhat conflicting, the therapist might then seek guidance from a more formal authority. Specifically, a natural step would be to seek out the professional code of ethics governing the therapist’s mental health field. In the case of a social worker, this would mean the NASW Code; a certified counselor, including a marriage and family therapist or other licensed mental health therapist, would likely examine the NBCC Code; a clinical psychologist would consult the APA Code.

Reviewing any of the above-mentioned codes for guidance in addressing this dilemma, one might reasonably reach the conclusion that the confidentiality of all of the client’s statements should be maintained unless there are “compelling professional reasons” (NASW Code, Ethical Standard 1.07c), a need to prevent “clear and imminent danger to the client or others” (NBCC Code, Section B4), or it is necessary to “protect the client/patient, (professional), or others from harm” (APA Code, Ethical Standard 4.05b), making it appropriate to reveal them. Perhaps the present situation might constitute such a “compelling” reason, but this conclusion would rely at least in part on the therapist’s subjective interpretation of the rather broad language used in the standard. Delving further into any of these codes, one might discover the professional obligation to help clients set their own personal goals and identify their own paths in life (NASW Code, Ethical Standard 1.02, governing self-determination), or the professional’s burden to respect the integrity and promote the welfare of the client (NBCC Code, Section B1), or the requirement that the professional take reasonable steps to avoid harming their clients/patients and others with whom they work (APA Code, Ethical Standard 3.04). Perhaps the therapist might justifiably observe that any of these duties would conflict with some of the other choices the therapist has already considered.

Delving still further into an appropriate code, the therapist might uncover more ethical standards suggesting even broader societal aims that the professional is admonished to promote, such as the commitment to seek social justice (NASW Code, Ethical Standard 6.01), the prevention of exploitation of individuals and groups (NASW Code, Ethical Standard 6.04d), the protection of public confidence in professional practice (NBCC Code, Section A13), and the minimization of harm where it is foreseeable and unavoidable (APA Code, Ethical Standard 3.04). All of these responsibilities certainly might have some application in the present scenario.

How can the therapist resolve all of these seemingly inconsistent obligations? Reviewing any of the aforementioned codes will quickly reveal that the ethical responsibilities outlined in them are not rank ordered, so not much guidance is provided in the way of establishing which standards may take precedence. Therefore it may be perplexing trying to get clear direction from an ethical code on the issue of what precisely to do in this scenario.

Bewildered by the array of possible issues to be considered, the therapist in this example might decide to contact a personal or agency attorney in order to learn more about the applicable legal responsibilities in the state in which the therapist practices. The therapist might learn from the attorney that a relevant licensing law requires professionals, including psychotherapists, social workers, counselors, psychologists, and other mental health providers to keep all of their clients’ communications confidential, except when they represent a threat of future violence or criminal activity. The attorney could reasonably suggest that, based on this law, the therapist’s client is entitled to keep his past conduct a secret in the context of his psychotherapy, and to hold the therapist to a bond of confidentiality. In other words, the attorney might advise, the therapist is legally obliged to take no formal action concerning this client’s statements.

This may be the technically correct legal answer, but is it also the right practice decision? Put differently, is the answer consistent with the therapist’s clinical and therapeutic goals? The therapist’s attorney might suggest that it is, because if one violates the law, jail is the outcome. Not swayed by this pragmatic argument, the therapist might express a sense of idealistic frustration to the attorney. The attorney is likely to respond that the law is based on good public policy, which suggests that this client, like all clients who seek out the help of mental health professionals, would be far less likely to have done so without the implicit understanding that what is told to the professional is private and must not go beyond the consultation room. Thus, the attorney might suggest, one should probably be thankful that the client has felt secure enough to seek consultation, where now at least the opportunity exists to help him work on all of the issues that have driven him to seek assistance. Without this law, in all probability the unfortunate story the client has revealed would never have been brought to the surface in the first place. Perhaps, the attorney might counsel, continued clinical work is possible with this client in a manner that upholds the law, but that also fulfills some of the objectives of applicable professional standards.

Does the “right” legal answer inevitably point the way toward the best clinical practice decision in all professional dilemmas? As the preceding scenario suggests, assessing the legal impact of a professional dilemma at the very least leads to a more effective and efficient consideration of the range of practice options available to the decision maker. Therefore, the legal assessment is an inseparable part of thorough professional decision making.